Richard Rathe, MD

Patients who are actively engaged with their health have better outcomes. Good communication is key. I made this Patient Instructions Card about six months ago and have been very pleased with it. I’ve turned it into a generic PDF with custom name, phone and tobacco resource fields. Fill in your particulars and have it printed at 50% on card stock. Enjoy!

This is the first release of quickHPI for general use by students, residents and clinicians. It is based on version 1.1 with persistent client-side data storage added. Once installed, it can be used offline when network connectivity is unavailable or undesired.

QuickHPI is both a tutorial and a practical tool for recording the History of Present Illness. As such it has wide applicability in medical education and patient care. The program instantiates my research into best practices for outpatient documentation aka The Rational History of Present Illness.

The best clinical documentation is that which gives to the reader the greatest amount of information in the shortest time with the fewest pixels.

During April 2014 I gave a talk at an EMR meeting concerning the changes manifest in the everyday clinic note. Most are familiar with various approaches to generating notes that meet all requirements for billing, compliance, and liability. Patient care and physician efficiency frequently suffer. I am particularly concerned about “note bloat” and the tendency of automated systems to add noise and imprecision to medical documentation. I’ve been working with our EMR vendor to create a better approach to the History of Present Illness.

This is sample output from a template driven tool that does NOT attempt to generate english prose. For this hypothetical patient, the structured approach yields a complete HPI in 48 words and 290 characters (60 words if you count the labels). Also note the judicious use of directly typed input (in blue). One of the biggest problems I see with EMR templates is they over specify. Why check a box for a phrase that is sort of what you’re thinking when in a few words you can say precisely what you mean?! Now contemplate how easy it is to visually scan and assimilate the information. As Dr. Tufte would say, “there is very little Pfuff!” Least Ink in action!!

To sum up his talk in two words, both the Intensity and Complexity of care have increased in the past forty years. This is not surprising when you think about it. What aspect of life in the US has not become more intense and complex? He focuses on how the education of physicians lags behind the realities of team-based care. This is a valid point as far as it goes. He does not speculate on why “even primary care physicians” are specialists and no one is charged with understanding the entire spectrum of care for individual patients? (So I will…) In a word, Economics! During the 1990s Medicare and other payers decided to stop paying for coordination of care by primary care physicians. This was exacerbated by division of outpatient and inpatient care in the past ten years (again primarily for economic reasons). The new focus on high-volume, episodic care leaves little time for the big picture. This is not a flaw in medical education and not a choice made by primary care physicians! Merely the predictable consequence of decisions made by insurers and the federal government.

The US Supreme Court is about to hear arguments for and against the recent healthcare insurance reform law enacted by Congress. (aka The Affordable Care Act, aka Obamacare) At issue is the constitutionality of the individual mandate to buy health insurance. It is unclear whether they will set new precedent or rule on a much narrower basis. Their decision could have profound effects on the current law and future legislation. Partisans on both sides of this issue should welcome a broad decision and be ready to accept the consequences!

If the mandate is found to be constitutional, this strengthens the notion that private insurance has a significant role to play in our mixed healthcare system. It bolsters popular components of the law that limit insurance companies’ ability to deny coverage for pre-existing conditions, place lifetime caps on benefits, and allow young adult children to remain on their parents’ insurance. The real challenge—reining in the exploding costs of healthcare—is still ahead of us.

If the mandate is found to be unconstitutional, this is the best argument yet for a single payer system in the US. You cannot have a viable healthcare insurance system if a significant number of citizens have the ability to opt out when they’re young and healthy. Beware the law of unintended consequences! If it turns out to be unconstitutional to force broad participation in private insurance, can a public option be far behind? Careful what you wish for!

I recently updated my lecture on cough, given to third-year medical students and residents. It presents an algorithm I developed based on the omnibus supplement published in the journal Chest and other sources. Here is a quick summary of key points that are often missed by primary care physicians…

Acute cough is largely due to viral infections and therefore antibiotics are NOT indicated.

There is growing evidence that first generation antihistamines are the drugs of choice for undifferentiated acute cough.

Post-infectious cough is the most common etiology for cough lasting between 3-8 weeks.

Secondary causes of cough (reactive airways, GERD, post-nasal drip) should be considered based on symptoms and time course.

In areas of high TB prevalence consider testing for active disease in any patient with a cough lasting more than two weeks (WHO recommendation).

It is useful to think of the secondary history as a Focused Review of Systems (ROS). These questions often bring out information that supports a certain diagnosis or helps gauge the severity of the disorder. Unlike the primary history, a certain amount of interpretation (and experience) is necessary.

The tertiary history brings in elements of the Past Medical and Family History that have a bearing on the patient’s condition. By the time you get to the tertiary history you may already have a good idea of what might be going on. Read More…

This is a great documentary from 2008 that explores how other wealthy countries deal with healthcare. The corespondent T.R. Reid visits five capitalist countries that provide affordable, nearly universal coverage for their citizens. How do they do it? He observes that here in the US we have the British model for veterans, the Taiwanese model for seniors, the German model for workers with insurance, but for the rest we are “just another poor country”. His conclusions…

1) Insurance companies must accept everyone, and cannot make a profit on basic care.

2) Everybody is mandated to buy insurance, with the government paying the premiums for the poor.

3) Doctors and hospitals have to accept one standard set of fixed prices.

Being able to handle emotional situations is an important interviewing skill. It is safe to assume that every patient has some form of emotional response to significant illness. There is also growing evidence that an individual’s emotional state can effect or even cause physical disease. The patient will often give you several clues that should be followed up. Read more…

At the most basic level, insurance is all about sharing risk. For example, a group of one thousand homeowners band together to create an insurance pool to protect against fire. If homes are worth $100,000 and there is one fire per year, they would have to chip in $100 each. Fortunately the risky event is rare, so the cost of insurance is low.

Now let’s compare this with insuring health. We have the same thousand people, of which five hundred consume an average of $10,000 in healthcare services each year. Illness unfortunately is not a rare event and the annual premium jumps to $5,000 per person! Many of the younger, healthier people ask why they should be paying for somebody else’s infirmity? They withdraw from the pool and premiums skyrocket. Eventually the pool collapses and those who actually need care loose their coverage, and in many cases financial ruin ensues.

The key difference is that almost everyone will utilize healthcare services at some point in their lives. It’s as if fifty houses burn down every year, not just one. The insurance model breaks down under these circumstances. We are no longer sharing risk but rather sharing the cost of something that is deemed essential by a large number of our peers.

The two obvious solutions are controlling costs and enlarging the pool. Recent mandates to buy health insurance are an attempt to address the latter. Controlling the cost of healthcare continues to be a conundrum.

Richard RatheDr. Rathe joined the University of Florida in 1990 to develop the informatics program for the College of Medicine. Prior to his arrival, he completed a two year informatics fellowship at the Harvard
School of Public Health. More...
Follow me on Twitter!